Geneva Lake Manor: Infection Control Failures Found - WI
The nurse, identified in inspection records as RN-M, also rolled the facility's shared treatment cart directly into each resident's room during the procedures, then pushed it back out into the hallway when finished.
Inspectors observed the first incident on the morning of February 27, 2025. RN-M knocked on the door of Resident 17, pushed the treatment cart inside, and performed wound care. No gown was worn. A nursing assistant, CNA-O, was present throughout. Neither put on a gown. When the wound care was done, RN-M pushed the cart back out into the hall. CNA-O followed.
When a surveyor stopped CNA-O in the hallway and asked what personal protective equipment should be worn when a resident is in enhanced barrier precautions, CNA-O said a gown. The surveyor asked what would put a resident on those precautions. CNA-O said a wound or a catheter. The surveyor asked whether Resident 17 was on precautions. CNA-O said they did not know, so they did not wear one.
The bin outside Resident 17's room had gowns in the drawers. CNA-O had walked past it.
Less than an hour later, at 10:29 a.m., RN-M walked down the hall to Resident 19. A sign on the door stated that Resident 19 was in enhanced barrier precautions due to a heel wound. RN-M knocked, pushed the treatment cart inside, and performed the wound treatment. Again, no gown. When finished, RN-M pushed the cart back into the hallway.
That afternoon, surveyors sat down with the facility's nursing home administrator and director of nursing and walked through both incidents. The administrator and director of nursing were told that RN-M had entered two rooms under enhanced barrier precautions without a gown, and that the treatment cart had been brought into both rooms and then returned to the hallway. The inspection record notes that no additional information was supplied by the facility.
RN-M, when asked directly by a surveyor whether a gown should have been worn while performing wound care in a resident's room, said yes. When asked whether RN-M should have put one on before treating Resident 17, the answer was again yes.
Enhanced barrier precautions are used when a resident carries an organism that standard precautions alone are not enough to contain. The precautions are meant to protect other residents, staff, and the shared equipment that moves between rooms. A treatment cart that rolls into a room under those precautions and then back out into the hallway becomes a surface that connects every subsequent room it enters.
The inspection covered many residents, according to the deficiency citation.
Geneva Lake Manor is a nursing facility at 211 South Curtis Street in Lake Geneva. The inspection was completed March 17, 2025, and the deficiency was cited at a level of minimal harm or potential for actual harm.
What the record does not resolve is how many times the cart made that trip before a surveyor happened to be watching.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Geneva Lake Manor from 2025-03-17 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 6, 2026 · Our methodology
Geneva Lake Manor in Lake Geneva, WI was cited for violations during a health inspection on March 17, 2025.
Inspectors observed the first incident on the morning of February 27, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.